The Halachic Medical Directive

The Halachic Medical Directive ADVANCE DIRECTIVE WITH RESPECT TO HEALTH CARE DECISIONS AND POST- MORTEM DECISIONS FOR USE IN NEW JERSEY The Halachic Medical Directive is designed to help ensure that all medical and post-death decisions made by others on your behalf will be made in accordance with Jewish law and custom (halacha). The text of this Halachic Medical Directive has been approved by attorneys for use in your state as of November, 2003. While we do not expect that any future change in federal or state laws would materially affect the validity of this document, you may wish to show it to your own attorney to confirm its effectiveness in subsequent years. INSTRUCTIONS (a) Please print your name on the first line of the form. (b) In Section 1, print the name, address, and telephone numbers of the person you wish to designate as your health care representative to make medical decisions on your behalf if, G-d forbid, you ever become incapable of making them on your own. Be sure to include all numbers (including cell phone and pager) where your representative can be reached in the event of an emergency. If the contact information for your representative changes, you should provide that updated information to everyone whom you have provided with a copy of your Halachic Medical Directive. You may also insert the name, address, and telephone numbers of an alternate representative to make such decisions if your main representative is unable, unwilling, or unavailable to make such decisions. It is recommended that before appointing anyone to serve as your representative or alternate representative you should ascertain that person s willingness to serve in such capacity. In addition, if you have made arrangements with a burial society (Chevra Kadisha), you may wish to advise your representatives of such arrangements. Note: You may appoint any competent adult to serve as your health care representative (an adult is a person 18 years of age or older) except an operator, administrator or employee of a health care institution in which you are a patient or resident, unless such person is your relative. You may appoint your physician as your representative, however, under New Jersey law he or she cannot act as both your representative and your attending physician at the same time, so appointing your physician is not recommended. (c) In section 3, please print the name, address, and telephone numbers of the Orthodox Rabbi whose guidance you want your representative to follow, should any questions arise as to the requirements of halacha. You should then print the name, address, and telephone numbers of the Orthodox Jewish institution or organization you want your representative to contact for a referral to another i

Orthodox Rabbi if the rabbi you have identified is unable, unwilling or unavailable to provide the appropriate consultation and guidance. You are, of course, free to insert the name of any Orthodox Rabbi or institution/organization you would like, but before doing so it is advisable to discuss the matter with the rabbi or institution/organization to ascertain their competency and willingness to serve in such capacity. You may list Agudath Israel of America as the organization you select; however, we are only available to be contacted on regular business days and hours. (d) In Section 7, sign and print your name, address, phone numbers, and the date. If you are not physically able to do these things, New Jersey law allows another person to sign and date the form on your behalf, as long as he or she does so at your direction, in your presence, and in the presence of two adult witnesses. (e) In the DECLARATION OF WITNESSES Section, two witnesses should sign their names and insert their addresses beneath your signature. These two witnesses must be competent adults (age 18 or older). Neither of them should be the person you have appointed as your health care representative (or alternate representative. They may, however, be your relatives. As an alternative to the witness requirement, this form can be acknowledged by you before a notary public, attorney at law, or other person authorized to administer oaths. A Certificate of Acknowledgement of Notary Public is included in this form. (f) It is recommended that you keep the original of this form among your valuable papers in a location that is readily accessible in the event of an emergency; and that you distribute copies to the health care representative (and alternate representative) you have designated in section 1, to the rabbi and institution/organization you have designated in section 3, as well as to your doctors, your lawyer, and anyone else who is likely to be contacted in times of emergency. We also recommend that you register a copy of this form with a national registry, so that it can be accessed by any health care facility via computer. Agudath Israel has made an arrangement with the New York Legal Assistance Group to register Halachic Medical Directives for our constituents with the U.S. Living Will Registry at no charge. To obtain the forms to enable you to do so, e-mail NJdirective@agudathisrael.org or call our office (212-797- 9000). Please note that this Directive will not become operative until: (i) it is transmitted to your attending physician or to the health care institution, and (ii) it is determined by your attending physician that you lack capacity to make a particular health care decision. (g) If at any time you wish to revoke this Advance Directive, you may do so by executing a new one; or by notifying your representative or health care provider, or other reliable witness, orally or in writing, of your intent to revoke. To avoid possible confusion, it would be wise to try to obtain all originals and copies of the old Advance Directive and destroy them. If you do not revoke the Advance Directive, New Jersey law provides that it remains in effect indefinitely. Obviously, if any of the persons you have appointed in the Advance Directive dies or becomes otherwise incapable of serving in the role you have assigned, it would be wise to execute a new Advance Directive. Please note that the designation of your spouse as representative will be revoked upon divorce or legal separation, unless otherwise specified in the Halachic Medical Directive. ii

(h) It is recommended that you also complete and cut out the Emergency Instructions Card contained on the last page of this Halachic Medical Directive, and carry it with you in your wallet or purse. (i) If, upon consultation with your rabbi, you would like to add to this standardized Advance Directive any additional expression of your wishes with respect to medical and/or post-mortem decisions, you may do so by attaching a rider to the standardized form. If you choose to do so, or if you have any other questions concerning this form, please consult an attorney. These instructions are not part of the Halachic Medical Directive and need not be kept attached to the executed document. Developed and published by: Agudath Israel of America 42 Broadway, 14 th Floor New York, NY 10004 212-797-9000 iii

ADVANCE DIRECTIVE WITH RESPECT TO HEALTH CARE DECISIONS AND POST-MORTEM DECISIONS FOR USE IN NEW JERSEY I,, hereby declare as follows: 1. Appointment of Health Care Representative: In recognition of the fact that there may come a time when I will become unable to make my own health care decisions because of illness, injury or other circumstances, I hereby appoint Representative Name of Representative: Address: Telephone: Day: Evening: Cellular phone: Pager: as my health care representative ( representative ) to make any and all health care decisions for me, consistent with my wishes as set forth in this directive. If the person named above is unable, unwilling or unavailable to act as my representative, I hereby appoint Alternate Representative Name of Alternate Representative: Address: Telephone: Day: Evening: Cellular phone: Pager: to serve in such capacity. This appointment shall take effect in the event I become unable, because of illness, injury or other circumstances, to make my own health care decisions. 2. Jewish Law to Govern Health Care Decisions: I am Jewish. It is my desire, and I hereby direct, that all health care decisions made for me (whether made by my representative, a guardian appointed for me, or any other person) be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. Without limiting in any way the generality of the foregoing, it is my wish that Jewish law and custom should dictate the course of my health care with respect to such matters as the performance of cardio-pulmonary resuscitation if I suffer cardiac or respiratory arrest; the performance of 1

life-sustaining surgical procedures and the initiation or maintenance of any particular course of lifesustaining medical treatment or other form of life-support maintenance, including the provision of nutrition and hydration; and the criteria by which death shall be determined, including the method by which such criteria shall be medically ascertained or confirmed. 3. Ascertaining the Requirements of Jewish Law: In determining the requirements of Jewish law and custom in connection with this declaration, I direct my representative to consult with the following Orthodox Rabbi and I ask my representative to follow his guidance: Rabbi Name of Rabbi: Address: Telephone: Day: Evening: Cell: Pager/beeper: If such Orthodox Rabbi is unable, unwilling or unavailable to provide such consultation and guidance, then I direct my agent to consult with, and I ask my agent to follow the guidance of, the following Orthodox Rabbi: Rabbi Name of Rabbi: Address Telephone: Day: Evening: Cell: Pager/beeper: If both of these Orthodox Rabbis are unable, unwilling or unavailable to provide such consultation and guidance, then I direct my agent to consult with, and I ask my agent to follow the guidance of, an Orthodox Rabbi referred by the following Orthodox Jewish institution or organization: Organization Name of Institution/Organization: Address: Telephone: Day: Evening: If such institution or organization is unable, unwilling or unavailable to make such a reference, or if the Orthodox Rabbi referred by such institution or organization is unable, unwilling or unavailable to provide such guidance, then I direct my representative to consult with, and I ask my representative to follow the guidance of, an Orthodox Rabbi whose guidance on issues of Jewish law and custom my representative in good faith believes I would respect and follow. 2

4. Direction to Health Care Providers: Any health care provider shall rely upon and carry out the decisions of my representative, and may assume that such decisions reflect my wishes and were arrived at in accordance with the procedures set forth in this directive, unless such health care provider shall have good cause to believe that my representative has not acted in good faith in accordance with my wishes as expressed in this directive. If the persons designated in section 1 above as my representative and alternate representative are unable, unwilling or unavailable to serve in such capacity, it is my desire, and I hereby direct, that any health care provider or other person who will be making health care decisions on my behalf follow the procedures outlined in section 3 above in determining the requirements of Jewish law and custom. Pending contact with the representative and/or Orthodox Rabbi described above, it is my desire, and I hereby direct, that all health care providers undertake all essential emergency and/or life sustaining measures on my behalf. 5. Access to Medical Records and Information; HIPAA: My health care representative is my personal representative, as such term is defined under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), and accordingly all of my protected health information (as such term is defined under HIPAA) and other medical records shall be made available to my health care representative upon request in the same manner as such information and records would be released and disclosed to me, and my health care representative shall have and may exercise all of the rights I would have regarding the use and disclosure of such information and records, as required under HIPAA. 6. Post-Mortem Decisions: It is also my desire, and I hereby direct, that after my death, all decisions concerning the handling and disposition of my body be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. For example, Jewish law generally requires expeditious burial and imposes special requirements with regard to the preparation of the body for burial. It is my wish that Jewish law and custom be followed with respect to these matters. I further direct that my health care representative be responsible for the disposition of my remains. Further, subject to certain limited exceptions, Jewish law generally prohibits the performance of any autopsy or dissection. It is my wish that Jewish law and custom be followed with respect to such procedures, and with respect to all other post-mortem matters including the removal and usage of any of my body organs or tissue for transplantation or any other purposes. I direct that any health care provider in attendance at my death notify the representative and/or Orthodox Rabbi described above immediately upon my death, in addition to any other person whose consent by law must be solicited and obtained, prior to the use of any part of my body as an anatomical gift, so that appropriate decisions and arrangements can be made in accordance with my wishes. Pending such notification, and unless there is specific authorization by the Orthodox Rabbi consulted in accordance with the procedures outlined in paragraph 3 above, it is my desire, and I hereby direct, that no post-mortem procedure be performed on my body. 7. Incontrovertible Evidence of My Wishes: If, for any reason, this document is deemed not legally effective as a health care proxy, or if the persons designated in section 1 above as my representative and alternate representative are unable, unwilling or unavailable to serve in such capacity, I declare to my family, my doctor and anyone else whom it may concern that the wishes I have expressed herein with regard to compliance with Jewish law and custom should be treated as incontrovertible evidence of my intent and desire with respect to all health care measures and post-mortem procedures; and that it is my wish that the procedure outlined in section 3 above should be followed in determining the requirements of Jewish law and custom. 8. Duration and Revocation: It is my understanding and intention that unless I revoke this Advance Directive, it will remain in effect indefinitely. My signature on this document shall be deemed to constitute a 3

revocation of any prior health care proxy, directive or other similar document I may have executed prior to today's date. My Signature Signature: (If you are not physically capable of signing, please ask another person to sign your name on your behalf.) Print Name: _ Date: Address: Telephone: Day: Evening: DECLARATION OF WITNESSES I, on this day of, 20, declare that the person who signed (or asked another to sign) this document is personally known to me and appears to be of sound mind and acting willingly and free from duress and undue influence. He/She signed (or asked another to sign for him/her) this document in my presence (and that person signed in my presence). I am not the person appointed as representative by this document. Witnesses Witness 1: SIGNATURE Print Name: Residing at: Witness 2: SIGNATURE Print Name Residing at: Developed and published by: Agudath Israel of America 42 Broadway, 14 th Floor New York, NY 10004 212-797-9000 4

CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC (TO BE USED IN LIEU OF WITNESSES) STATE OF ) :ss.: COUNTY OF ) On this day of, in the year 20, before me,, personally (insert name of notary public) appeared, personally known to me (insert name of principal) (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it. I declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be sound of mind and under no duress, fraud, or undue influence. NOTARY SEAL (signature of notary public) 5

Emergency Instructions I, have executed a Halachic Medical Directive with respect to medical and post-mortem decisions, dated. Pursuant to the Halachic Medical Directive the persons listed on the reverse of this card are to serve as my agent and alternate agent, respectively, in making health care decisions for me if I become unable to do so on my own. I desire that all such health care decisions, as well as all decisions relating to the handling and disposition of my body after I die, should be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. If there is any questions regarding Jewish law and custom, my agent (or any other person making decisions for me) should consult with and follow the guidance of the rabbi identified on the reverse of this card, or as a second choice the rabbi referred by the institution/organization identified on the reverse of this card, or as a third choice an Orthodox Rabbi whose guidance my health care decision maker in good faith believes I would respect and follow. Pending contact with my agent and/or rabbi, I desire that health care providers should undertake all essential emergency measures on my behalf; and I desire that no autopsy, organ removal, or other post mortem procedure be performed on my body without authorization from my agent and/or rabbi. Fold on the dotted line to create a double sided card ------------------------------------------------------------------------------------------------------------------------------------------------------------- EMERGENCY INSTRUCTIONS Agent: Phone Evening: Cell: Alternate Agent: Phone: Evening: Cell: Rabbi: Phone: Evening: Cell Organization Phone: 6

Agudath Israel of America, in partnership with the New York Legal Assistance Group (NYLAG) would like to encourage you to register your Halachic Medical Directive for free with the U.S. Living Will Registry. The Registry will maintain a copy of your Halachic Medical Directive on a secure website that can be accessed instantly by any health care facility. We encourage registration because in many cases, a patient has to be rushed to a hospital and the family cannot locate the Halachic Medical Directive. The Registry solves this problem and therefore ensures that your health care wishes will be respected. (If you were to register on your own, there is a cost for the service. However, if you register through NYLAG, this service is provided at no cost.) Benefits of registration are: 1. The U.S Living Will Registry provides a wallet-sized card with your special identification number. The information on that card allows for a medical professional to view your Halachic Medical Directive at any time of the day or night. This provides peace of mind to yourself and your loved ones. No one will have to search for these vital documents should you become incapacitated since the only information the health care facility needs is readily available in your wallet or purse. 2. The U.S Living Will Registry issues a new card every twelve months. This will allow you to remember to update any new information (change in telephone numbers, addresses or even change of appointed Health Care Proxy.) To register your Halachic Medical Directive, all you need to do is complete the U.S. Living Will Registry Registration Agreement (attached.) Please note that if you do not feel comfortable providing your Social Security Number, you do not have to do so. Please attach a clear copy of your Halachic Medical Directive to the U.S. Living Will Registry Registration Agreement, and send both documents to: New York Legal Assistance group Total Life Choices Program 7 Hanover Square New York, NY 10004 Or fax them to (212) 750-0820 Information about the New York Legal Assistance Group may be found at: www.nylag.org Information about the U.S. Living Will Registry may be found at: www.uslivingwillregistry.com

Source Code U.S. Living Will Registry Registration Agreement 37125901 Registrant s Identifying Information (Please type or print clearly) Name: First Middle Last Suffix Social Security Number: Date of Birth: Month Day Year (4 digits, please) Address - Primary Residence: Street Address Apt # City State Zip Code Secondary Residence (if any): Street Address Apt # City State Zip Code Phone- Home: ( ) Work: ( ) Secondary Res: ( ) Emergency Contact #1: Name: Relationship: Address: Telephone Number: Home: ( ) Work/Other: ( ) Emergency Contact #2: Name: Relationship: Telephone Number: Home: ( ) Work/Other: ( ) I, ("Registrant" or I ), request that the U.S. Living Will Registry, with offices at 523 Westfield Ave., PO Box 2789 Westfield, New Jersey 07091-2789 ( Registry ), electronically store a copy of my attached advance directive (collectively, including but not limited to my: living will, health care proxy, or similar document[s], including organ donor information, provided to the Registry), and provide a copy of the stored advance directive image to any health care provider who requests it in conjunction with my care. A health care provider is any hospital, doctor, skilled nursing facility, nursing facility, home health care agency/provider, ambulatory surgery facility, hospice, or any authorized employee, contractor or agent of any of the foregoing, or other person believed charged with giving effect to my advance directive or assisting in same. I voluntarily execute this registration on the date set forth below, without coercion, duress or undue influence from any party, and I warrant and represent that I have the legal capacity to offer my consent to such registration. My registration is not effective until I receive written confirmation from the Registry, at the above address. I can only register through a Registry member Health Care Provider or a Registry Community Partner. The Registry s member Health Care Providers and Community Partners are not owned or operated by the Registry, and they cannot change any terms of this Registration Agreement; any oral changes are not effective. Only the Registry can change the terms of the Registration Agreement, and only in writing (except in emergencies, in the Registry s sole discretion). I have provided my Social Security number to facilitate the identification, retrieval and provision of my stored advance directive images to health care providers, and for the Registry s recordkeeping purposes only. I. Registration and Certification: I submit the information contained herein to confirm my identity, in the event that a health care provider requests a copy of my advance directive. I certify that this information is correct and that the attached advance directive is my currently effective advance directive, which was properly executed in accordance with the laws of the state where it was executed. If the attached advance directive is a copy, I certify that it is a true and correct copy of the

original document. I agree to immediately notify the Registry, in writing, at the Registry s address listed above, in the event of my revocation of the attached advance directive or of this registration, or if the attached advance directive or the identifying information herein are changed in any way. I agree immediately to provide the Registry with a copy of the new/changed documents. I will indemnify and hold the Registry harmless for any damages resulting from the Registry s reliance on these certifications, or on any inaccurate information I supplied. If I don t notify the Registry in writing and in a timely manner of any changes, or of the revocation of my advance directive or this registration, or if I don t provide a true copy of the changed documents to the Registry, the Registry will not be liable for any damages resulting from the production of the documents on file to any health care provider. If my information is accessed over the Internet utilizing my unique registration number, my social security number ( SSN ) will not be revealed, and it will not be visible or disclosed on the Registry s web page. If the card containing my unique registration number is lost or otherwise unavailable, health care providers will be able to access my documents using my SSN. Since most health care providers have access to their patients SSN, providing your SSN to the Registry ensures the widest availability of your advance directive images to health care providers in time of need, even when your card is not available. The Registry will take appropriate steps to safeguard the privacy and confidentiality of each Registrant s SSN, and the Registry will not use SSNs for any purposes not specifically permitted by this Registration agreement. If you do not provide your SSN, your documents will be identified only by the unique registration number assigned by the Registry, which will significantly limit the accessibility of your documents. II. Authorization: I authorize the Registry to send a copy of my advance directive to any health care provider (as defined herein) that requests a copy of it, provided the request conforms to the Registry s policies and procedures (or as deemed advisable by the Registry in an emergency situation, or as required by law). The Registry is not otherwise authorized to share my personal information with parties other than health care providers (as defined herein). A copy of this Agreement may be used in place of the original document. III. Limitations on Liability: I understand that I will not be charged a fee to register or to maintain my registration. Registry shall not be liable to me or any person or entity for any liability arising from the improper transmission/disclosure of my advance directive, from the transmission of inaccurate or incomplete materials, or from the loss/misplacement/destruction/unavailability of all or part of my advance directive. If I don t agree to these terms, I am free not to use the Registry s service. IV. Term: This Agreement shall remain in effect until Registry receives reliable information that the Registrant is deceased, the Registrant requests, in writing, that the Agreement be terminated, or until registration is cancelled pursuant to the Registry s policies and procedures. When the Agreement is terminated, Registry will use best efforts to remove Registrant s advance directive from its files. I hereby agree to the terms herein, and certify the accuracy of the information provided. I agree to safeguard my Registration ID card from unauthorized access. I understand that anyone who gains access to my card can use it to gain access to my documents and personal information (but not to my SSN), and I will not hold the Registry liable for such unauthorized access. X DATED: / / Signature of Registrant WITNESS STATEMENT I declare that the Registrant who signed this document is personally known to me, that he/she signed or acknowledged this document in my presence, and that he/she appears to be of sound mind, and under no duress or undue influence. Signature: Print Name: (Witness #1) DATED: / / Signature: Print Name: (Witness #2) DATED: / /